Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: September 2021

SHFT’s Complaints, Concerns and Compliments Policy and Procedure documents should be urgently reviewed and reformed. They should be combined into a single document. The policy should prioritise service users, family members and carers. SHFT should work with these groups to co-produce it. It must be clear, straightforward and in an easily understood format. All members of staff must undertake mandatory training on the new Policy and Procedure.

SHFT should clarify what complaints management system is actually in place in the organisation, whether this is centralised or locally managed, and further go on to ensure the system is publicised and shared in clear language with staff, service users, family members and carers.

SHFT should clarify and define the role of PALS and if proceeding with it, co-design and co-produce a strategy and implementation plan for its development throughout the organisation. The service must be accessible, supportive and responsive to service user and carer needs.

SHFT should urgently implement a process to monitor the quality of the investigation of complaints, complaint reports and responses and the impact of recommendations from complaints. That system should test the extent to which outcomes and judgments are evidence-based, objective and fair.

SHFT should re-develop its Complaints Handling leaflet that reflects the complaints process, outlines expectations and timelines for service users, family members and carers. It must be co-designed and co-produced with these groups. The documents should be widely available to all in paper and digital format.

During the investigation of complaints, SHFT should offer the opportunity for face-to-face meetings as a matter of course. These meetings should provide the time to discuss with complainants about how they wish their complaint to be handled and a timeframe for a response, should be agreed. SHFT should maintain communication with the complainant throughout, with a full explanation for any delays.

SHFT should ensure that all complainants that go through its complaints handling process, have access to advocacy services where required. SHFT should be alert to the importance of perceived independence of representation. Therefore, it should look to Third sector organisations that it can to facilitate access or signpost their availability for complainants. This should be co-ordinated so as to be part of the complaints handling process.

There is a vital and continuing need for SHFT to re-build trust and confidence with the population it serves. To achieve this end SHFT should continue its move away from a past unresponsive culture and defensive language. Today, SHFT acknowledge the need to balance accountability and responsibility by ensuring that it meets the Duty of Candour and admits its mistakes. To achieve this, SHFT needs to ensure all staff are trained and understand the Duty of Candour and take a positive pro-active approach in all future engagement with families, carers, and service users, to ensure that their needs are met.

SHFT should co-produce with service users, carers and family members, a Communications Strategy to identify a ‘road map' for improving communications. This should include, but is not limited to, mandatory training on communication across the whole of SHFT, including improving internal communications and the development of a protocol setting out how SHFT will provide support to its service users, carers and family members. It should create specific roles to provide this support. SHFT recruitment processes should include good and effective communication skills criteria for all roles at every level of the organisation.

SHFT should develop a Carer’s Strategy, in which the aims and actions are understood and are to be articulated by carers, working together with staff. As a minimum, these actions should be reviewed annually at a large-scale event with carers at the centre. In future, carers must have the opportunity to articulate their needs and the actions needed to address them. Part of this process should be the enhancement and wider use of the Carer’s Communication Plan, which must be underpinned by relevant training.

SHFT should ensure all staff are all rapidly trained to understand the Triangle of Care and that these principles are clearly communicated across SHFT to all staff to ensure greater awareness. The Quality Improvement methodology should be used to measure the impact of the Triangle of Care.

SHFT should set up regular localised drop-in sessions and groups for carers and remote carers, which provides support and advice to meet local needs, to include ongoing peer support.

The Panel recommends that SHFT strengthens its links with the local Hampshire Healthwatch, to ensure that the voices of service users, family members and carers are heard locally. This relationship should be formalised and monitored through a quarterly feedback session between SHFT and Hampshire Healthwatch, with a written report that is publicly available.

SHFT should pay due regard to the 7th principle and 8th principle of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. Through training, supervision and support, staff need to be empowered to apply these principles in everyday practice and SHFT should be transparent about how it does so.

SHFT should seek to improve both the quality of the handover and the sharing of information between clinicians involved in patient care, to include nursing, medical, therapy and pharmacy staff. This should extend, where relevant, to all care settings, including, SHFT and General Practices across its divisions.

SHFT must make swifter progress in developing the Patient Experience Dashboard to ensure that it is able to triangulate data and information effectively. It should consider using the data from the Triangle of Care processes to inform this Dashboard. It should also implement specific audits of carer feedback at a local level.

SHFT should adopt the Patient Safety Response Incident Framework and National Standards for Patient Safety Investigations (published by NHSE/I in March 2020) for reporting and monitoring processes, when they are introduced nationally.

It is recommended that future NHS patient safety frameworks for Serious Incidents should acknowledge and incorporate the different needs of patient groups, such as physical health, mental health and learning disability and the unique context in which the incident took place.

SHFT should provide a clear and transparent definition of ‘independence’ and an open and accessible explanation about its processes for ensuring its investigations are ‘independent’. The definition and explanation should be available to service users, carers and family members and staff. SHFT should also set out criteria which indicate when an independent and external investigation in respect of a Serious Incident will be conducted and who, or which organisation, will commission it.

In the case of an enquiry into a Serious Incident that requires an external independent investigation, there should be a fully independent and experienced Chair, the background and qualities of whom should be specific to the facts of the case subject to investigation.

Following a Serious Incident, SHFT should ensure that families, carers and service users, with limited resources, can access external legal advice, support, or advocacy services, as required. Due to potential conflicts of interests, SHFT should not fund such support services directly, but should explore options with local solicitor firms and Third sector or not-for-profit organisations, to facilitate access or signpost their availability.

The job description for SHFT’s Investigation Officer role should include specific qualities required for that post. The minimum qualities should include, integrity, objectivity and honesty.

SHFT should develop a more extensive Investigation Officer training programme, which includes a shadowing and assessment process. Service users, family members, carers and clinical staff should be involved in the development of this programme. It should include, but is not limited to, regular refresher training, a structured process for appraisals, a continuous professional development plan and reflective practice. This will ensure continuous quality improvement in the centralised investigations team.

SHFT should urgently change and improve the Ulysses template for investigation reports to ensure that all completed investigation reports are accessible, readable, have SMART recommendations and demonstrate analysis of the contributory and Human Factors.

All completed investigation reports in SHFT should explicitly and separately document the details of family and carer involvement in the investigation, in compliance with any data protection and confidentiality issues or laws.

SHFT must share learning more widely throughout the whole organisation and ensure that staff have ready access to it. The Trust should ensure staff attend learning events to inform their practice.

SHFT should have in place, as a priority, a mechanism for capturing the views and feedback of the service user, family member and carer about the entire SI investigation process. This should be monitored at regular intervals for learning purposes and should be shared with the central investigations team and the Board.

SHFT should improve the quality of the Initial Management Assessments that are provided to the 48-hour Review Panel to ensure that the decision-making process for the type of investigation required is robust, rigorous and timely. This should be done through a systematic training model and quality assurance mechanisms should be put in place.

SHFT should produce a quarterly and annual Serious Incidents Report, which should provide a mechanism for quality assurance. It should be presented to the Board and available to the general public, in compliance with data protection and confidentiality laws.

The SHFT Board and the Quality and Safety Committee should receive more information on the degree of avoidable harm and the lessons learnt, through regular reporting. Thereafter, that information should be discussed by the Board and shared through the Quality Account and Annual Report and with the general public, in compliance with data protection and confidentiality laws. It should address not only the quantitive analysis of all incidents, but it should also reflect a thorough qualitative analysis to identify the relevant themes of current error and future themes for learning.

SHFT should recognise, implement and develop the role of the Medical Examiner, in line with forthcoming national legislation and guidance.

SHFT should examine the potential of expanding and bringing together the Patient Safety Specialists into a team, led by a Director of Patient Safety, from the Executive level.

SHFT should develop a co-produced Patient Safety Plan, which includes a long-term strategy for the recruitment of Patient Safety Specialists and Patient Safety Partners and a commitment to continuous improvement.

The CCG should monitor its contract with SHFT with demonstrable rigour and perceived independence.

The establishment of the newly formed Integrated Care Service provides an opportunity to strength the service delivered by the shared specialist Mental Health and Learning Disability Team. Therefore, the team should be acknowledged and implanted in the ICS in the next 12 months.

All Action Plans that are created by SHFT, at any level of the organisation, should include a deadline and the name of an individual(s) and their role, who is responsible for taking forward the action indicated. They must be monitored to ensure they have been implemented and shared for learning.

SHFT should introduce a Board-level monitoring system for action plans and the implementation of recommendations made during investigations. That process should require tangible evidence to be provided of actions of improvement and learning. That process should be documented and reported on regularly.

SHFT should adopt the NHS Just Culture Guide and put in place an implementation plan to ensure its uptake through its ongoing organisational development and staff training programme. It should ensure that it is well placed within the SHFT recruitment strategy and within all induction programmes for all staff, to particularly include substantive and locum medical staff.

SHFT should work to ensure that the membership of its sub-committees and its Staff Governors is increased and diversified, so that it better represents the population it serves. It should work with its Governors to do so. This should form part of a long term strategy and the impact of it should be measured, monitored and reported on through formalised structured processes.